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Increasing Engagement in Evidence-Based PTSD Treatment Through Shared Decision-Making: A Pilot Study Juliette M. Mott, PliD*ft; Melinda A. Stanley, PliD*U; Richard L. Street Jr., PhD*§¡¡; Rebecca H. Grady, BA*U; Bien J. Teng, PhD*ft ABSTRACT Within the Veterans Health Administratioti. post-traumatic stre.ss disorder (PTSD) treatment decisiotis are left to the patient and provider, allowing substantial variability in the way treatment decisions are made. Theorized to increase treatment engagement, shared decision-making interventions provide a standardized fratnework for treatment decisions. This study sought to develop (phase 1) and pilot test the feasibility and potential effectiveness (phase 2) of a brief shared decision-making intervention to promote engagetnent in evidence-based PTSD treatment. An initial version of the intervention was developed and then modified according to stakeholder feedback. Participants in the pilot trial were 27 Iraq and Afghanistan Veterans recruited during an intake assessment at a Veterans Affairs PTSD clinic. Participants randomized to the intervention condition {n = 13) participated in a 30-minute shared decision-making session, whereas patients randotnized to the usual care condition (/¡ = 14) completed treatment planning during their intake appointment, per usual clinic procedures. Among the 20 study completers, a greater propotiion of participants in the intervention condition prefen'ed an evidence-based treatment and received an adequate (>9 sessions) dose of psychotherapy. Results provide preliminary support for the feasibility and potential effectiveness of the intervention and suggest that larger-scale trials are warranted.
INTRODUCTION The past 2 decades have seen bourgeoning empirical support for the effectiveness of psychotherapy in treating posttraurnatic .stress disorder (PTSD). Clinical practice guidelines universally endorse psychotherapy as a first-line treatment for PTSD and identify cognitive behavioral treatments as among the most effective.''^ The Veterans Health Administration (VHA) has identified 2 evidence-based psychotherapy (EBP) protocols. Prolonged Exposure (PE)^ and Cognitive Processing Therapy (CPT),'* and has initiated large-scale rollouts of these treatments.'' Despite increased availability, the VHA reports low rates of initiation and completion of EBP for FTSD.^ A growing body of research on barriers to mental health treatment has enhanced understanding of factors contributing to low psychotherapy utilization. In addition to more widely recognized factors, such as stigma and distance to care,^'*^ insufficient understanding of treatments has also emerged as a critical barrier to care for Veterans with PTSD.'^'" Indeed, a recent U.S. Government Accountability Office report" cited "lack of understanding or awareness of rnental health care" as one of 4 key barriers inhibiting engagement in VHA mental *VA HSR&D Center of Excellence, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Boulevard, Houston, TX 77030. tVA South Central Mental Illness Research, Education and Clinical Center (a Virtual Center), Houston, TX. tMenninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030. §Department of Medicine, Baylor College of Medicine. Houston, TX. ||Department of Communication. Texas A&M University, 3116 TAMU, 407 Richardson Building. College Station. TX 77843. The views expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs, the U.S. government, or Baylor College of Medicine. doi: 10.7205/MILMED-D-13-00363
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health care. Patients lacking awareness or understanding of treatment options rnay be less likely to initiate treatment for a variety of reasons, including anxiety about what to expect and uncertainty about how therapy can help.'"•'"' Patients with insufficient treatment knowledge may also be at risk of initiating a treatment with which they are not well matched, commonly cited as a reason for premature dropout.'"* To promote well-informed treatment decisions and achieve an optimal patient-treatment match, it is critical that patients receive comprehensive and accurate information about their treatment options. Within the VHA, PTSD treatment decisions are typically left to the patient and the provider,"^''^ leaving room for substantial variability in the amount of time spent discussing options, information presented, and degree of Veteran involvement. Broadly, VHA guidelines regarding decisionmaking for mental health treatment indicate that the patient, and whenever possible the patient's family, should partici16 Since 2012, the VHA has also pate in treatment decisions.'* required the offer of PE and/or CPT to all Veterans with a primary diagnosis of PTSD.'^ However, there is little in the way of guidelines or interventions to educate providers about specific techniques to engage patients in PTSD care decisions or provide guidance on how to introduce these protocols. Thus, decision-making processes surrounding PTSD treatments in the VHA remain largely unstandardized and may contribute, in part, to low rates of EBP utilization. Preliminary research exarnining PTSD treattnent decisions suggests that the manner of presentation of treatment options can impact patients' receptivity to EBP.'**''^ Patient perceptions of the mechanism and effectiveness of treatment are key factors influencing participants' preference for EBP,^"'"^' which underscores the importance of educating patients in
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these domains. These prior studies, however, have evaluated the impact of various informational resources, such as brochures and videotaped treatment descriptions, reviewed outside the context of a medical or mental health visit. Given that PTSD treatment decisions in the VHA most often occur during patient-provider encounters, an important next step in this line of research is to evaluate the utility of decision aids and interventions that facilitate a collaborative approach to treatment planning by the patient and provider. Shared decision-making (SDM) interventions provide a consistent framework for treatment decision-making and can enhance PTSD treatment decisions. SDM is a process by which patients are provided with current and accurate information regarding their diagnosis, treatment options, outcomes, and side effects. A provider facilitates this process by helping the patient explore his or her treatment goals and comfort with the potential benefits and risks of treatment alternatives, with the goal of selecting a preferred treatment.^^'""* SDM interventions have been widely tested within other medical and mental health populations; within depressed patients, for example, SDM is linked with higher rates of treatment initiation^''; and it has been shown to indirectly influence treatment outcome via treatment adherence.^^ Although the benefits of SDM have yet to be examined within a PTSD population, SDM is theorized to increase treatment engagement through mechanisms that may be particularly relevant to patients with PTSD. First, SDM interventions standardize the treatment decision-making process, which can help to ensure that all PTSD patients are wellinformed about important factors that influence EBP receptivity (e.g., treatment rationale and mechanisms). SDM also promotes engagement by enhancing patients' understanding of treatment options. During SDM, providers assess patients' treatment knowledge, creating an opportunity to identify and correct common misconceptions about EBP. Einally, SDM increases treatment commitment by conferring agency for the treatment decision to the patient. Patients actively involved in treatment decisions are believed to experience greater decision control than they would experience without active involvement, which, in turn, increases treatment commitment and motivation. PTSD patients may experience some EBP techniques (e.g., exposure exercises) as challenging, and commitment to treatment is critical to continued treatment engagement. Given the potential of SDM to enhance PTSD treatment decisions, the goal of this study was to develop a novel SDM intervention to assist Veterans in making well-informed choices about PTSD care and promote EBP utilization (phase 1) and to examine its feasibility and potential effectiveness (phase 2). PHASE 1: SDM INTERVENTION DEVELOPMENT Phase 1 Overview During initial development, a preliminary version of the intervention was created by the study team. An existing
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SDM model'^^"^^ served as the underlying framework. The intervention featured 4 PTSD treatments commonly offered within VHA PTSD programs, selected because they provided a range of options regarding treatment intensity, format, and effectiveness: CPT, PE, Anxiety Management Training, and PTSD Education (described below). Stakeholders (Veterans, providers, PTSD treatment experts) gave feedback on materials, and the intervention was modified according to this feedback.
Methods Participants
Veteran stakeholders included 8 Veterans enrolled in the VHA PTSD clinic, recruited via provider referral. All had coinpleted a tour in Iraq or Afghanistan and carried a current or previous PTSD diagnosis in their medical record. Eour had completed one of the featured treatments, and 4 had not received prior psychotherapy for PTSD. Providers included 4 VHA providers (3 psychologists and 1 postdoctoral fellow) who routinely provided psychotherapy in the PTSD clinic and had attended a VHA workshop in CPT, PE, or both. PTSD treatment experts included 2 consultants for the national VHA PE and CPT dissemination initiatives, both psychologists. SDM Intervention
Initial materials included an intervention manual to standardize the decision-making process and a 12-page patient decision aid (PDA) developed according to International PDA Standards.^^ The manual and PDA highlighted CPT, PE, Anxiety Management Training, and PTSD Education. CPT and PE are 8- to 12-week cognitive behavioral treatments that target PTSD symptoms. PE is an individual treatment during which patients repeatedly recount the details of their trauma and approach avoided situations to decrease associated fear and anxiety. CPT, administered in individual or group format, helps patients reduce PTSD symptoms by changing unhelpful trauma-related thoughts. PTSD Education is a 5-week group program designed to help patients and family members learn about PTSD, and Anxiety Management Training is an 8-week group treatment that educates patients about general anxiety and teaches anxiety-reduction strategies. The SDM intervention manual guides clinicians through a 30-minute decision-making session. The intervention was based on an existing decision-making model by Elwyn et a\,^^'^^ which identifies SDM components, including "choice talk," a planning step in which the provider indicates that a choice exists and that the patient can have a role in treatment decisions; "option talk," during which the provider gives detailed information about benefits/risks, mechanisms, and effectiveness of treatments using decision-support tools (i.e., PDA); and "decision talk," during which the patient and provider dialogue about preferences, eventually eliciting a decision. The intervention manual included example scripts
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and prompts for describing and discussing treatment options. Treatment information consisted of nontechnical, factual statements that described the intervention name, purpose, components, mechanisms, effectiveness, potential discomforts, client/therapist roles, and frequency."^ The PDA included a comparison chart that summarized the central aspects of each featured treatment and briefly described alternative PTSD treatments, inviting patients to request further details about these options. A copy of the FDA is available on request to the first author. Measures
An intervention-feedback form was used to elicit stakeholder feedback on the intervention. The form queried the amount of information provided for each treatment (4 items), the clarity with which risks and benefits were communicated (1 item), and overall readability (1 item) on a 5-point, Likert-type scale. Three open-ended prompts queried perceived strengths of the intet-vention, the degree to which participants believed the intervention would facilitate treatment discussions between patients and providers, and suggestions as to how to improve the intervention.
Veterans to ask for additional detail and clarification about the treatments"—Treattnent expert). Stakeholders also identified several areas for improvement. In particular. Veterans requested that the intervention include tnore information on what they would be asked to do in therapy ("For CPT, there's nothing on what you do in therapy"—Veteran); whereas providers and PTSD treatment experts encouraged additional detail regarding the rationale and effectiveness of featured treatments ("I think the reader may understand what the treatments entail but may understand less how or why repeatedly talking about their trauma, or writing about their thoughts and emotions, could potentially alleviate symptoms"—Treatment expert). Notably, 7 of the 8 Veteran stakeholders recotnmended changes to the pictures in the initial PDA, requesting neutral pictures that would be unlikely to trigger upsetting memories and that would provide a realistic, visual depiction of what therapy would be like (e.g., "Put a picture of a group so they know what they are getting into"—Veteran). In response to feedback, the intervention was revised to better meet stakeholder needs. Before pilot testing, additional information about treatment tasks, rationale, and mechanisms was added and pictures used in the decision aid were modified.
Procedures
Stakeholders received a copy of preliminary intervention materials and an overview of intervention goals and purpose. Stakeholders reviewed intervention tnaterials independently and then completed the intervention-feedback form.
Results All stakeholders gave the highest possible rating for readability and clarity of risks and benefits. Nine of the 13 stakeholders requested additional information about at least one featured treatments, most often CPT (/; = 5). No stakeholders indicated that the intervention should include less information about any featured treatments. Open-ended feedback about the strengths of the intervention indicated that stakeholders perceived that it provided important treatment education (e.g., "It took me 2 years to know what treatments were offered here. I wish I would have had something like this."—Veteran). Both Veterans and treattnent experts acknowledged the benefits of having an enduring document to review outside appointments and potentially share with family (e.g., "It gives me something to review. Some guys have memory issues and need to see it, not hear it."—Veteran; "I think it is an excellent educational guide that [Veterans] can take home and look over and share with fatnily tnembets"—Treattnent expert). When queried about how the intervention may impact decision-making interactions between patients and providers, all PTSD treatment experts and providers, and a subset of Veteran stakeholders (n = 5, 63%), reported that they believed the intervention would increase patients' motivation to talk with their provider about treattnent options (e.g., "I think it will compel
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PHASE 2: PILOT TESTING
Phase 2 Overview Veterans with PTSD were recruited for a small pilot trial examining the feasibility and preliminary effectiveness of the SDM intervention. Participants were randomized to one of 2 treatmetit decision-tnaking conditions: SDM (n = 13) or usual care (UC; n - 14). Participants' treatment preferences were assessed by their provider in the context of the SDM or UC decision-making encounter. At 4-month follow-up, participants' tnental health service use was assessed via medical-record review, and SDM patients were invited to give feedback on the SDM intervention duritig a semistructured exit interview.
Methods Participants
Phase 2 participants were 27 Iraq and Afghanistan Veterans who participated in an intake assessment at a large VHA PTSD clinic. Per eligibility criteria, all participants were diagnosed with PTSD and had served at least one tour in Iraq or Afghanistan. PTSD diagnosis was confirmed with the PTSD Symptom Checklist at ba.selitie; all participants had a total score above 50 (M = 60.3; SD = 15.5), the recomtnended cutoff for a probable PTSD."** Participants were excluded if they had received prior VHA psychotherapy for their PTSD symptoms or were previously entolled in the PTSD clinic, as indicated in their medical record. Participants were predominantly male (n = 23, 85%) and white (n = 19, 70%) and ranged in age from 22 to 47 years (M = 29.3,
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SD = 5.5). At intake, 41% of the sample were married or cohabitating, 33% were single, and 26% were separated or divorced. On average. Veterans had 13.4 (SD = 1.8) years of education and reported an annual household income of $27,336 (SD = $15,692). Six (22%) were receiving disability benefits for PTSD. Half the sample (« = 14) carried a diagnosis of a comorbid axis I disorder in addition to PTSD; depressive disorders (« = 10, 37%) and anxiety disorders (77 ~ 5, 19%) were the most common comorbidities. iVIeasures Patient Feedback
We assessed patient perspectives on the SDM intervention through a telephone-based, semistructured exit interview. Given that the interview queried specific aspects of the SDM intervention, it was conducted with a subset of SDM completers in = 5); we did not conduct exit interviews with UC participants because they had no exposure to the SDM intervention. The exit interview was exploratory in nature and was used to begin to identify potential strengths and limitations related to the feasibility and acceptability of the intervention. Open-ended protnpts queried 3 domains: satisfaction with SDM, perceived advantages of SDM, and perceived disadvantages of SDM. A member of the study team not involved in the administration of the SDM intervention conducted the interviews by telephone. Treatment Preferences
SDM and UC providers queried patients about their treatment preferences. UC providers were instructed to use their usual methods to determine the degree to which they discussed treatment options with patients and the questions they used to determine preference. SDM providers were asked to adhere to the SDM manual and to use example prompts for assessing preference (e.g., "Do you have a sense of which treatment might be the best fit for you?"). Preferences for patients in both groups were recorded in patients' medical records and subsequently extracted via chart review. Treatment Engagement
Use of psychotherapy within the PTSD clinic during the 4-month follow-up period was assessed via medical record review. A data-extraction form was used to record information on the following variables: psychotherapy initiation (>1 sessions), adequate dose of psychotherapy (>9 sessions),'' type of psychotherapy (if any) received (e.g., PE, CPT, supportive psychotherapy), and total number of missed psychotherapy visits (i.e., a scheduled visit that the patient neither attended nor canceled).
over a 4-month period and ended when programmatic changes restructuring in the PTSD clinic resulted in changes to available treatment options. Participants were randomized to SDM or UC using a computer-generated randomization sequence, and randomization envelopes were prepared by the study statistician to ensure that study staff remained masked to randomization sequence. SDM participants received the PDA immediately following consent and could select to complete the SDM session itnmediately or within 7 days. The SDM session consisted of a 30-minute visit with a doctoral-level provider. Study staff communicated the SDM participants' treatment preferences to the PTSD clinic treatment team. Per usual clinic procedures, UC participants worked with their PTSD clinic provider during the intake appointment to determine a preferred treatment. UC providers were psychologists, postdoctoral fellows, or social workers who worked in the PTSD clinic. Participation in the study did not restrict patients' treatment options; the full range of PTSD clinic treatments, including medication management and alternative psychotherapy options (e.g., supportive psycho therapy), were available to all participants. To ensure that participants received equal attention from study staff, UC participants attended a 30-minute placebo session during which they completed neutral, clinician-administered tasks assessing cognitive abilities. SDM and placebo sessions could be completed in person or via phone. At 4-month follow-up, study staff reviewed participants' medical records to extract information on treatment preferences and engagement. Medical-record reviews were conducted by a single rater trained in use of the dataextraction form. A second rater, masked to initial ratings, reextracted data from 20% of patients. Reliability analysis revealed acceptable-to-good agreement on extracted variables, including treatment preference (K = 1.00), type of PTSD treatment received (K = 0.68), and number of psychotherapy visits (K= 1.00).
Data Analysis Feasibility of the SDM intervention was evaluated with rates of study recruitment and retention and with an exit interview with a subset of SDM participants. Preliminary effectiveness was assessed with descriptive data on treatment preferences and treatment utilization for study completers (i.e., patients who received the SDM or placebo session) from the SDM (« = 9) and UC (« = 11) conditions. Data are presented descriptively, given that the small sample size precluded statistical significatice testing of differences between study conditions. RESULTS
Procedures
Feasibility
Veterans were referred to the study by their PTSD clinic intake provider and consented by study staff during their PTSD clinic intake appointment. Recruittnent took place
Recruitment and Retention
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Of the 28 Veterans referred to the study, 27 were consented and enrolled. The UC and SDM conditions evidenced similar
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completion rates, with 1\% {n ~ 11) of UC participants and 69% (n = 9) of SDM participants attending the SDM or placebo session. SDM Fatient Feedback
All SDM patients who participated in the exit interview (n - 5, 55% of completers) reported being satisfied with the intervention. When queried about the helpful aspects of the intervention, SDM patients identified 2 primary strengths. First, they reported that the intervention provided them with important treatment information (e.g., "The appointment in which I learned about PTSD treatments was private, not too long, and full of information"; "I liked the fact that they created a brochure explaining the main points of each treatment, which I could take with me and review in more detail at home"). Second, they reported that the intervention offered desired opportunities for involvement in decision-making (e.g., "I could explore it for myself, research it on my own"; "I like to know what's going on, so if you handed it to me a la carte, I might not have been as receptive as actually reading and learning about the treatments and picking what suited me best"; "You have a more active role in picking treatment"). Disadvantages of the intervention centered around the possibility that some Veterans may lack insight into their problems and may benefit from the provider's taking a more active role in treatment decision-making (e.g., "some [Veterans] could pick the most noninvasive course of action, might not realize that their problem is bad"; "Some Veterans are better off having someone else give them advice on how to approach their problems").
Preliminary Effectiveness
TABLE II.
Psychotherapy Visits by Study Condition During 4-Month Follow-up Period
Psychotherapy Visits
SDM (« = 9)
UC(«= II)
0 1-8 >9 Data presented for study completers only. SDM. shared decision-tiiaking; UC, usual care.
options, and 2 expressed a preference for "no treatment." Seven SDM participants (67%) selected an EBP (either CPT or PE) as their preferred treatment; in contrast, no UC participants (0%) selected an EBP. CPT was the most commonly preferred treatment among SDM participants, whereas PTSD 101 (an 8-week group focusing on psychoeducation and skills building) was the most commonly preferred treatment for UC participants. Treatment Engagement
Table II displays psychotherapy utilization data for study completers by condition. SDM and UC participants initiated therapy at similar rates (SDM: n = 4, 44%; UC: n - 5, 45%). All SDM participants who engaged in psychotherapy (H = 4) received 9 or more sessions, 3 of whom received 9 or more sessions of an EBP (all 3 received CPT). Only 1 UC participant received 9 or more sessions; no UC patients received an EBP. There were no instances in which a participant in either condition received a nonpreferred treatment. SDM patients with at least one scheduled psychotherapy visit {n - 1) had an average of 1.9 (SD = 1,9) missed appointments, compared to 1.3 (SD = 0.9) missed appointments among UC participants with a scheduled visit (« = 7).
Treatment Freferences
Data on treatment preferences were collected from the 20 study completers (Table I). Although patients could identify multiple preferences, most identified a preference for a single type of psychotherapy (n = 15). Two participants preferred 2 psychotherapy options, 1 preferred 3 psychotherapy Patient Treatment Preferences by Study Condition
Type Featured Treatments
Other Treatments
Treatment CPT Prolonged Exposure Anxiety Management PTSD Education PTSD 101 Seeking Safety Supportive Psychotherapy PTSD Inpatient Program Sexual Trauma Outpatient Program Not Interested in Treatment
SDM
UC
L/1
TABLE 1.
1 1 1 0 1 0 0 0
0 0 0 1 4 1 3 2 1
1
1
Patients could select more than one treatment option. SDM, shared decisionmaking; CPT, cognitive processing therapy; PTSD, post-traumatic stress disorder; UC, usual care.
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DISCUSSION This study evaluated the feasibility and preliminary effectiveness of an SDM intervention to promote engagement in EBP for PTSD. Results support the feasibility of the intervention, with SDM and UC participants showing similar completion rates. Patient-identified strengths of the SDM intervention were that it provided desired information about treatment options and allowed patients to play an active role in their treatment decisions. Preliminary effectiveness of the intervention was assessed by evaluating the treatment preferences and psychotherapy use of SDM and UC participants. Consistent with prior literature indicating low EBP use arnong Veterans with PTSD,^'"' 0% of UC participants identified a VHA-endorsed EBP (CPT or PE) as a preferred treatment. In contrast, most SDM participants (67%) selected an EBP. These findings may indicate that PTSD patients are willing to self-select emotionally demanding but effective treatments when they are wellinformed about options and involved in decision-making. UC participants, in contrast, may not have been infonned of EBP availability, and those informed of EBP availability
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may not have been made aware of key factors known to influence EBP receptivity. Regarding service use, a similar proportion of SDM and UC participants initiated psychotherapy for PTSD in the 4-month follow-up period. However, more SDM (33%) than UC participants (0%) received EBP. In addition, more SDM participants (100%) than UC participants (9%) received guideline-concordant care (>9 sessions). The larger dose of psychotherapy received by SDM participants is consistent with prior research in other mental health populations, indicating that patients involved in treatment decisions are less likely to terminate prematurely."^•''° Patient involvement in decision-making is believed to convey to the patient that he or she is capable of making sound decisions, thereby increasing treatment commitment.^' SDM is also theorized to foster patient-provider alliance in that the provider gives transparent information about treatments and conveys respect for the patient's preferences. The elements of transparency and respect are particularly relevant to trauma survivors, who report that mistrust for mental health professionals is a treatment deterrent.32
Limitations and Future Directions Results were limited to descriptive analysis, given the sample size, and adequately powered trials need to evaluate intervention effectiveness more rigorously. This study did not evaluate the decision-making techniques used in the UC condition; although some UC providers may already be using SDM, the observed differences between SDM and UC participants suggest that providers may not be using these practices consistently. Data regarding PTSD treatment effectiveness were not available, but future studies should examine the impact of SDM on treatment outcome. In addition, an important future step is to evaluate the intervention when administered by existing clinicians during routine care. The intervention could be subsumed feasibly into a routine intake appointment, which would not require patients to attend a separate decision-making session, and would likely improve SDM completion rates. Research in this area should seek to identify potential batriers and facilitators to the use of SDM in clinical care and determine when SDM can be most effective (e.g., after screening for PTSD, on referral to PTSD clinics). A more comprehensive understanding of these factors can inform the future development and refinement of effective SDM interventions. CONCLUSIONS Pilot testing of a brief SDM intervention for Veterans with PTSD indicated that, compared with UC patients, more SDM patients selected an EBP as their preferred treatment. Although SDM was not associated with increased rates of psychotherapy initiation, SDM participants received a greater dose of psychotherapy. Although SDM has shown effectiveness with other populations, this study is the first to show its
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potential for PTSD. Given significant underuse of psychotherapy among Veterans with PTSD,''"'-^'' increasing PTSD treatment engagement is a critical mission for the VHA. SDM may be a promising strategy by which clinicians can facilitate participation in evidence-based protocols. Results from this study provide preliminary support for the SDM intervention and suggest that larger-scale controlled trials are warranted. ACKNOWLEDGMENTS This research was supported by the Office of Academic Affiliations VA Advanced Fellowship Program in Mental Illness Research and Treatment, the Department of Veterans Affairs South Central Mental Illness Research Education and Clinical Center (MIRECC), and the VA HSR&D Houston Center of Excellence (HEP90-020).
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24. Dwight-Johnson M, Unutzer J, Sherboume C, Tang L, Wells KB: Can quality improvement programs for depression in primary care address patient preferences for treatment? Med Care 2001: 39: 934-44. 25. Loh A, Leonhart R. Wills CE, Simon D, Harter M: The impact of patient participation on adherence and clinical outcome in primary care of depression. Patient Educ Couns 2007; 65; 69-78. 26. Elwyn G. O'Connor A, Stacey D, et al; Developing a quality criteria framework for patient decision aids; online intemational Delphi consensus process. BMJ 2006; 333: 417-9. 27. Sidani S, Epstein DR, Bootzin RR, Moritz P. Miranda J: Assessment of preferences for treatment: validation of a measure. Res Nurs Health 2009; 32; 419-31. 28. Weathers F. Litz B, Herman D. Huska J, Keane T; The PTSD checklist (PCL); reliability, validity, and diagnostic utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies; October 1993; San Antonio, TX. 29. Mott JM. Mondragon SM, Hundt NE, Beason-Smith M, Grady RH, Teng EJ; Characteristics of Veterans who initiate and complete evidence-based psychotherapy for PTSD. J Trauma Stress (in press). 30. Gonzalez J, Williams JW. Hitchcock NP, Lee S: Adherence to mental health treatment in a primary care clinic. J Am Board Fam Med 2005; 18: 87-96. 31. Seligman ME: The effectiveness of psychotherapy. The Consumer Reports study. Am Psychol 1995; 50; 965-74. 32. Gorman LA, Blow AJ, Ames BD, Reed PL: National Guard families after combat: mental health, use of mental health services, and perceived treatment barriers. Psychiatr Serv 2011; 62; 28-34. 33. Cully JA. Tolpin L, Henderson L, Jimenez D, Kunik ME. Petersen LA; Psychotherapy in the veterans health administration; missed opportunities? Psychol Serv 2008; 5: 320-31. 34. Mott JM. Hundt NE. Sansgiry S, Mignogna J, Cully JC: Changes in psychotherapy utilization among veterans with depression, anxiety, and PTSD. Psychiatr Serv 2014; 65; 106-12.
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Increasing Engagement in Evidence-Based PTSD Treatment Through Shared Decision-Making: A Pilot Study Juliette M. Mott, PliD*ft; Melinda A. Stanley, PliD*U; Richard L. Street Jr., PhD*§¡¡; Rebecca H. Grady, BA*U; Bien J. Teng, PhD*ft ABSTRACT Within the Veterans Health Administratioti. post-traumatic stre.ss disorder (PTSD) treatment decisiotis are left to the patient and provider, allowing substantial variability in the way treatment decisions are made. Theorized to increase treatment engagement, shared decision-making interventions provide a standardized fratnework for treatment decisions. This study sought to develop (phase 1) and pilot test the feasibility and potential effectiveness (phase 2) of a brief shared decision-making intervention to promote engagetnent in evidence-based PTSD treatment. An initial version of the intervention was developed and then modified according to stakeholder feedback. Participants in the pilot trial were 27 Iraq and Afghanistan Veterans recruited during an intake assessment at a Veterans Affairs PTSD clinic. Participants randomized to the intervention condition {n = 13) participated in a 30-minute shared decision-making session, whereas patients randotnized to the usual care condition (/¡ = 14) completed treatment planning during their intake appointment, per usual clinic procedures. Among the 20 study completers, a greater propotiion of participants in the intervention condition prefen'ed an evidence-based treatment and received an adequate (>9 sessions) dose of psychotherapy. Results provide preliminary support for the feasibility and potential effectiveness of the intervention and suggest that larger-scale trials are warranted.
INTRODUCTION The past 2 decades have seen bourgeoning empirical support for the effectiveness of psychotherapy in treating posttraurnatic .stress disorder (PTSD). Clinical practice guidelines universally endorse psychotherapy as a first-line treatment for PTSD and identify cognitive behavioral treatments as among the most effective.''^ The Veterans Health Administration (VHA) has identified 2 evidence-based psychotherapy (EBP) protocols. Prolonged Exposure (PE)^ and Cognitive Processing Therapy (CPT),'* and has initiated large-scale rollouts of these treatments.'' Despite increased availability, the VHA reports low rates of initiation and completion of EBP for FTSD.^ A growing body of research on barriers to mental health treatment has enhanced understanding of factors contributing to low psychotherapy utilization. In addition to more widely recognized factors, such as stigma and distance to care,^'*^ insufficient understanding of treatments has also emerged as a critical barrier to care for Veterans with PTSD.'^'" Indeed, a recent U.S. Government Accountability Office report" cited "lack of understanding or awareness of rnental health care" as one of 4 key barriers inhibiting engagement in VHA mental *VA HSR&D Center of Excellence, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Boulevard, Houston, TX 77030. tVA South Central Mental Illness Research, Education and Clinical Center (a Virtual Center), Houston, TX. tMenninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030. §Department of Medicine, Baylor College of Medicine. Houston, TX. ||Department of Communication. Texas A&M University, 3116 TAMU, 407 Richardson Building. College Station. TX 77843. The views expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs, the U.S. government, or Baylor College of Medicine. doi: 10.7205/MILMED-D-13-00363
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health care. Patients lacking awareness or understanding of treatment options rnay be less likely to initiate treatment for a variety of reasons, including anxiety about what to expect and uncertainty about how therapy can help.'"•'"' Patients with insufficient treatment knowledge may also be at risk of initiating a treatment with which they are not well matched, commonly cited as a reason for premature dropout.'"* To promote well-informed treatment decisions and achieve an optimal patient-treatment match, it is critical that patients receive comprehensive and accurate information about their treatment options. Within the VHA, PTSD treatment decisions are typically left to the patient and the provider,"^''^ leaving room for substantial variability in the amount of time spent discussing options, information presented, and degree of Veteran involvement. Broadly, VHA guidelines regarding decisionmaking for mental health treatment indicate that the patient, and whenever possible the patient's family, should partici16 Since 2012, the VHA has also pate in treatment decisions.'* required the offer of PE and/or CPT to all Veterans with a primary diagnosis of PTSD.'^ However, there is little in the way of guidelines or interventions to educate providers about specific techniques to engage patients in PTSD care decisions or provide guidance on how to introduce these protocols. Thus, decision-making processes surrounding PTSD treatments in the VHA remain largely unstandardized and may contribute, in part, to low rates of EBP utilization. Preliminary research exarnining PTSD treattnent decisions suggests that the manner of presentation of treatment options can impact patients' receptivity to EBP.'**''^ Patient perceptions of the mechanism and effectiveness of treatment are key factors influencing participants' preference for EBP,^"'"^' which underscores the importance of educating patients in
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these domains. These prior studies, however, have evaluated the impact of various informational resources, such as brochures and videotaped treatment descriptions, reviewed outside the context of a medical or mental health visit. Given that PTSD treatment decisions in the VHA most often occur during patient-provider encounters, an important next step in this line of research is to evaluate the utility of decision aids and interventions that facilitate a collaborative approach to treatment planning by the patient and provider. Shared decision-making (SDM) interventions provide a consistent framework for treatment decision-making and can enhance PTSD treatment decisions. SDM is a process by which patients are provided with current and accurate information regarding their diagnosis, treatment options, outcomes, and side effects. A provider facilitates this process by helping the patient explore his or her treatment goals and comfort with the potential benefits and risks of treatment alternatives, with the goal of selecting a preferred treatment.^^'""* SDM interventions have been widely tested within other medical and mental health populations; within depressed patients, for example, SDM is linked with higher rates of treatment initiation^''; and it has been shown to indirectly influence treatment outcome via treatment adherence.^^ Although the benefits of SDM have yet to be examined within a PTSD population, SDM is theorized to increase treatment engagement through mechanisms that may be particularly relevant to patients with PTSD. First, SDM interventions standardize the treatment decision-making process, which can help to ensure that all PTSD patients are wellinformed about important factors that influence EBP receptivity (e.g., treatment rationale and mechanisms). SDM also promotes engagement by enhancing patients' understanding of treatment options. During SDM, providers assess patients' treatment knowledge, creating an opportunity to identify and correct common misconceptions about EBP. Einally, SDM increases treatment commitment by conferring agency for the treatment decision to the patient. Patients actively involved in treatment decisions are believed to experience greater decision control than they would experience without active involvement, which, in turn, increases treatment commitment and motivation. PTSD patients may experience some EBP techniques (e.g., exposure exercises) as challenging, and commitment to treatment is critical to continued treatment engagement. Given the potential of SDM to enhance PTSD treatment decisions, the goal of this study was to develop a novel SDM intervention to assist Veterans in making well-informed choices about PTSD care and promote EBP utilization (phase 1) and to examine its feasibility and potential effectiveness (phase 2). PHASE 1: SDM INTERVENTION DEVELOPMENT Phase 1 Overview During initial development, a preliminary version of the intervention was created by the study team. An existing
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SDM model'^^"^^ served as the underlying framework. The intervention featured 4 PTSD treatments commonly offered within VHA PTSD programs, selected because they provided a range of options regarding treatment intensity, format, and effectiveness: CPT, PE, Anxiety Management Training, and PTSD Education (described below). Stakeholders (Veterans, providers, PTSD treatment experts) gave feedback on materials, and the intervention was modified according to this feedback.
Methods Participants
Veteran stakeholders included 8 Veterans enrolled in the VHA PTSD clinic, recruited via provider referral. All had coinpleted a tour in Iraq or Afghanistan and carried a current or previous PTSD diagnosis in their medical record. Eour had completed one of the featured treatments, and 4 had not received prior psychotherapy for PTSD. Providers included 4 VHA providers (3 psychologists and 1 postdoctoral fellow) who routinely provided psychotherapy in the PTSD clinic and had attended a VHA workshop in CPT, PE, or both. PTSD treatment experts included 2 consultants for the national VHA PE and CPT dissemination initiatives, both psychologists. SDM Intervention
Initial materials included an intervention manual to standardize the decision-making process and a 12-page patient decision aid (PDA) developed according to International PDA Standards.^^ The manual and PDA highlighted CPT, PE, Anxiety Management Training, and PTSD Education. CPT and PE are 8- to 12-week cognitive behavioral treatments that target PTSD symptoms. PE is an individual treatment during which patients repeatedly recount the details of their trauma and approach avoided situations to decrease associated fear and anxiety. CPT, administered in individual or group format, helps patients reduce PTSD symptoms by changing unhelpful trauma-related thoughts. PTSD Education is a 5-week group program designed to help patients and family members learn about PTSD, and Anxiety Management Training is an 8-week group treatment that educates patients about general anxiety and teaches anxiety-reduction strategies. The SDM intervention manual guides clinicians through a 30-minute decision-making session. The intervention was based on an existing decision-making model by Elwyn et a\,^^'^^ which identifies SDM components, including "choice talk," a planning step in which the provider indicates that a choice exists and that the patient can have a role in treatment decisions; "option talk," during which the provider gives detailed information about benefits/risks, mechanisms, and effectiveness of treatments using decision-support tools (i.e., PDA); and "decision talk," during which the patient and provider dialogue about preferences, eventually eliciting a decision. The intervention manual included example scripts
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and prompts for describing and discussing treatment options. Treatment information consisted of nontechnical, factual statements that described the intervention name, purpose, components, mechanisms, effectiveness, potential discomforts, client/therapist roles, and frequency."^ The PDA included a comparison chart that summarized the central aspects of each featured treatment and briefly described alternative PTSD treatments, inviting patients to request further details about these options. A copy of the FDA is available on request to the first author. Measures
An intervention-feedback form was used to elicit stakeholder feedback on the intervention. The form queried the amount of information provided for each treatment (4 items), the clarity with which risks and benefits were communicated (1 item), and overall readability (1 item) on a 5-point, Likert-type scale. Three open-ended prompts queried perceived strengths of the intet-vention, the degree to which participants believed the intervention would facilitate treatment discussions between patients and providers, and suggestions as to how to improve the intervention.
Veterans to ask for additional detail and clarification about the treatments"—Treattnent expert). Stakeholders also identified several areas for improvement. In particular. Veterans requested that the intervention include tnore information on what they would be asked to do in therapy ("For CPT, there's nothing on what you do in therapy"—Veteran); whereas providers and PTSD treatment experts encouraged additional detail regarding the rationale and effectiveness of featured treatments ("I think the reader may understand what the treatments entail but may understand less how or why repeatedly talking about their trauma, or writing about their thoughts and emotions, could potentially alleviate symptoms"—Treatment expert). Notably, 7 of the 8 Veteran stakeholders recotnmended changes to the pictures in the initial PDA, requesting neutral pictures that would be unlikely to trigger upsetting memories and that would provide a realistic, visual depiction of what therapy would be like (e.g., "Put a picture of a group so they know what they are getting into"—Veteran). In response to feedback, the intervention was revised to better meet stakeholder needs. Before pilot testing, additional information about treatment tasks, rationale, and mechanisms was added and pictures used in the decision aid were modified.
Procedures
Stakeholders received a copy of preliminary intervention materials and an overview of intervention goals and purpose. Stakeholders reviewed intervention tnaterials independently and then completed the intervention-feedback form.
Results All stakeholders gave the highest possible rating for readability and clarity of risks and benefits. Nine of the 13 stakeholders requested additional information about at least one featured treatments, most often CPT (/; = 5). No stakeholders indicated that the intervention should include less information about any featured treatments. Open-ended feedback about the strengths of the intervention indicated that stakeholders perceived that it provided important treatment education (e.g., "It took me 2 years to know what treatments were offered here. I wish I would have had something like this."—Veteran). Both Veterans and treattnent experts acknowledged the benefits of having an enduring document to review outside appointments and potentially share with family (e.g., "It gives me something to review. Some guys have memory issues and need to see it, not hear it."—Veteran; "I think it is an excellent educational guide that [Veterans] can take home and look over and share with fatnily tnembets"—Treattnent expert). When queried about how the intervention may impact decision-making interactions between patients and providers, all PTSD treatment experts and providers, and a subset of Veteran stakeholders (n = 5, 63%), reported that they believed the intervention would increase patients' motivation to talk with their provider about treattnent options (e.g., "I think it will compel
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PHASE 2: PILOT TESTING
Phase 2 Overview Veterans with PTSD were recruited for a small pilot trial examining the feasibility and preliminary effectiveness of the SDM intervention. Participants were randomized to one of 2 treatmetit decision-tnaking conditions: SDM (n = 13) or usual care (UC; n - 14). Participants' treatment preferences were assessed by their provider in the context of the SDM or UC decision-making encounter. At 4-month follow-up, participants' tnental health service use was assessed via medical-record review, and SDM patients were invited to give feedback on the SDM intervention duritig a semistructured exit interview.
Methods Participants
Phase 2 participants were 27 Iraq and Afghanistan Veterans who participated in an intake assessment at a large VHA PTSD clinic. Per eligibility criteria, all participants were diagnosed with PTSD and had served at least one tour in Iraq or Afghanistan. PTSD diagnosis was confirmed with the PTSD Symptom Checklist at ba.selitie; all participants had a total score above 50 (M = 60.3; SD = 15.5), the recomtnended cutoff for a probable PTSD."** Participants were excluded if they had received prior VHA psychotherapy for their PTSD symptoms or were previously entolled in the PTSD clinic, as indicated in their medical record. Participants were predominantly male (n = 23, 85%) and white (n = 19, 70%) and ranged in age from 22 to 47 years (M = 29.3,
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SD = 5.5). At intake, 41% of the sample were married or cohabitating, 33% were single, and 26% were separated or divorced. On average. Veterans had 13.4 (SD = 1.8) years of education and reported an annual household income of $27,336 (SD = $15,692). Six (22%) were receiving disability benefits for PTSD. Half the sample (« = 14) carried a diagnosis of a comorbid axis I disorder in addition to PTSD; depressive disorders (« = 10, 37%) and anxiety disorders (77 ~ 5, 19%) were the most common comorbidities. iVIeasures Patient Feedback
We assessed patient perspectives on the SDM intervention through a telephone-based, semistructured exit interview. Given that the interview queried specific aspects of the SDM intervention, it was conducted with a subset of SDM completers in = 5); we did not conduct exit interviews with UC participants because they had no exposure to the SDM intervention. The exit interview was exploratory in nature and was used to begin to identify potential strengths and limitations related to the feasibility and acceptability of the intervention. Open-ended protnpts queried 3 domains: satisfaction with SDM, perceived advantages of SDM, and perceived disadvantages of SDM. A member of the study team not involved in the administration of the SDM intervention conducted the interviews by telephone. Treatment Preferences
SDM and UC providers queried patients about their treatment preferences. UC providers were instructed to use their usual methods to determine the degree to which they discussed treatment options with patients and the questions they used to determine preference. SDM providers were asked to adhere to the SDM manual and to use example prompts for assessing preference (e.g., "Do you have a sense of which treatment might be the best fit for you?"). Preferences for patients in both groups were recorded in patients' medical records and subsequently extracted via chart review. Treatment Engagement
Use of psychotherapy within the PTSD clinic during the 4-month follow-up period was assessed via medical record review. A data-extraction form was used to record information on the following variables: psychotherapy initiation (>1 sessions), adequate dose of psychotherapy (>9 sessions),'' type of psychotherapy (if any) received (e.g., PE, CPT, supportive psychotherapy), and total number of missed psychotherapy visits (i.e., a scheduled visit that the patient neither attended nor canceled).
over a 4-month period and ended when programmatic changes restructuring in the PTSD clinic resulted in changes to available treatment options. Participants were randomized to SDM or UC using a computer-generated randomization sequence, and randomization envelopes were prepared by the study statistician to ensure that study staff remained masked to randomization sequence. SDM participants received the PDA immediately following consent and could select to complete the SDM session itnmediately or within 7 days. The SDM session consisted of a 30-minute visit with a doctoral-level provider. Study staff communicated the SDM participants' treatment preferences to the PTSD clinic treatment team. Per usual clinic procedures, UC participants worked with their PTSD clinic provider during the intake appointment to determine a preferred treatment. UC providers were psychologists, postdoctoral fellows, or social workers who worked in the PTSD clinic. Participation in the study did not restrict patients' treatment options; the full range of PTSD clinic treatments, including medication management and alternative psychotherapy options (e.g., supportive psycho therapy), were available to all participants. To ensure that participants received equal attention from study staff, UC participants attended a 30-minute placebo session during which they completed neutral, clinician-administered tasks assessing cognitive abilities. SDM and placebo sessions could be completed in person or via phone. At 4-month follow-up, study staff reviewed participants' medical records to extract information on treatment preferences and engagement. Medical-record reviews were conducted by a single rater trained in use of the dataextraction form. A second rater, masked to initial ratings, reextracted data from 20% of patients. Reliability analysis revealed acceptable-to-good agreement on extracted variables, including treatment preference (K = 1.00), type of PTSD treatment received (K = 0.68), and number of psychotherapy visits (K= 1.00).
Data Analysis Feasibility of the SDM intervention was evaluated with rates of study recruitment and retention and with an exit interview with a subset of SDM participants. Preliminary effectiveness was assessed with descriptive data on treatment preferences and treatment utilization for study completers (i.e., patients who received the SDM or placebo session) from the SDM (« = 9) and UC (« = 11) conditions. Data are presented descriptively, given that the small sample size precluded statistical significatice testing of differences between study conditions. RESULTS
Procedures
Feasibility
Veterans were referred to the study by their PTSD clinic intake provider and consented by study staff during their PTSD clinic intake appointment. Recruittnent took place
Recruitment and Retention
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Of the 28 Veterans referred to the study, 27 were consented and enrolled. The UC and SDM conditions evidenced similar
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completion rates, with 1\% {n ~ 11) of UC participants and 69% (n = 9) of SDM participants attending the SDM or placebo session. SDM Fatient Feedback
All SDM patients who participated in the exit interview (n - 5, 55% of completers) reported being satisfied with the intervention. When queried about the helpful aspects of the intervention, SDM patients identified 2 primary strengths. First, they reported that the intervention provided them with important treatment information (e.g., "The appointment in which I learned about PTSD treatments was private, not too long, and full of information"; "I liked the fact that they created a brochure explaining the main points of each treatment, which I could take with me and review in more detail at home"). Second, they reported that the intervention offered desired opportunities for involvement in decision-making (e.g., "I could explore it for myself, research it on my own"; "I like to know what's going on, so if you handed it to me a la carte, I might not have been as receptive as actually reading and learning about the treatments and picking what suited me best"; "You have a more active role in picking treatment"). Disadvantages of the intervention centered around the possibility that some Veterans may lack insight into their problems and may benefit from the provider's taking a more active role in treatment decision-making (e.g., "some [Veterans] could pick the most noninvasive course of action, might not realize that their problem is bad"; "Some Veterans are better off having someone else give them advice on how to approach their problems").
Preliminary Effectiveness
TABLE II.
Psychotherapy Visits by Study Condition During 4-Month Follow-up Period
Psychotherapy Visits
SDM (« = 9)
UC(«= II)
0 1-8 >9 Data presented for study completers only. SDM. shared decision-tiiaking; UC, usual care.
options, and 2 expressed a preference for "no treatment." Seven SDM participants (67%) selected an EBP (either CPT or PE) as their preferred treatment; in contrast, no UC participants (0%) selected an EBP. CPT was the most commonly preferred treatment among SDM participants, whereas PTSD 101 (an 8-week group focusing on psychoeducation and skills building) was the most commonly preferred treatment for UC participants. Treatment Engagement
Table II displays psychotherapy utilization data for study completers by condition. SDM and UC participants initiated therapy at similar rates (SDM: n = 4, 44%; UC: n - 5, 45%). All SDM participants who engaged in psychotherapy (H = 4) received 9 or more sessions, 3 of whom received 9 or more sessions of an EBP (all 3 received CPT). Only 1 UC participant received 9 or more sessions; no UC patients received an EBP. There were no instances in which a participant in either condition received a nonpreferred treatment. SDM patients with at least one scheduled psychotherapy visit {n - 1) had an average of 1.9 (SD = 1,9) missed appointments, compared to 1.3 (SD = 0.9) missed appointments among UC participants with a scheduled visit (« = 7).
Treatment Freferences
Data on treatment preferences were collected from the 20 study completers (Table I). Although patients could identify multiple preferences, most identified a preference for a single type of psychotherapy (n = 15). Two participants preferred 2 psychotherapy options, 1 preferred 3 psychotherapy Patient Treatment Preferences by Study Condition
Type Featured Treatments
Other Treatments
Treatment CPT Prolonged Exposure Anxiety Management PTSD Education PTSD 101 Seeking Safety Supportive Psychotherapy PTSD Inpatient Program Sexual Trauma Outpatient Program Not Interested in Treatment
SDM
UC
L/1
TABLE 1.
1 1 1 0 1 0 0 0
0 0 0 1 4 1 3 2 1
1
1
Patients could select more than one treatment option. SDM, shared decisionmaking; CPT, cognitive processing therapy; PTSD, post-traumatic stress disorder; UC, usual care.
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DISCUSSION This study evaluated the feasibility and preliminary effectiveness of an SDM intervention to promote engagement in EBP for PTSD. Results support the feasibility of the intervention, with SDM and UC participants showing similar completion rates. Patient-identified strengths of the SDM intervention were that it provided desired information about treatment options and allowed patients to play an active role in their treatment decisions. Preliminary effectiveness of the intervention was assessed by evaluating the treatment preferences and psychotherapy use of SDM and UC participants. Consistent with prior literature indicating low EBP use arnong Veterans with PTSD,^'"' 0% of UC participants identified a VHA-endorsed EBP (CPT or PE) as a preferred treatment. In contrast, most SDM participants (67%) selected an EBP. These findings may indicate that PTSD patients are willing to self-select emotionally demanding but effective treatments when they are wellinformed about options and involved in decision-making. UC participants, in contrast, may not have been infonned of EBP availability, and those informed of EBP availability
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may not have been made aware of key factors known to influence EBP receptivity. Regarding service use, a similar proportion of SDM and UC participants initiated psychotherapy for PTSD in the 4-month follow-up period. However, more SDM (33%) than UC participants (0%) received EBP. In addition, more SDM participants (100%) than UC participants (9%) received guideline-concordant care (>9 sessions). The larger dose of psychotherapy received by SDM participants is consistent with prior research in other mental health populations, indicating that patients involved in treatment decisions are less likely to terminate prematurely."^•''° Patient involvement in decision-making is believed to convey to the patient that he or she is capable of making sound decisions, thereby increasing treatment commitment.^' SDM is also theorized to foster patient-provider alliance in that the provider gives transparent information about treatments and conveys respect for the patient's preferences. The elements of transparency and respect are particularly relevant to trauma survivors, who report that mistrust for mental health professionals is a treatment deterrent.32
Limitations and Future Directions Results were limited to descriptive analysis, given the sample size, and adequately powered trials need to evaluate intervention effectiveness more rigorously. This study did not evaluate the decision-making techniques used in the UC condition; although some UC providers may already be using SDM, the observed differences between SDM and UC participants suggest that providers may not be using these practices consistently. Data regarding PTSD treatment effectiveness were not available, but future studies should examine the impact of SDM on treatment outcome. In addition, an important future step is to evaluate the intervention when administered by existing clinicians during routine care. The intervention could be subsumed feasibly into a routine intake appointment, which would not require patients to attend a separate decision-making session, and would likely improve SDM completion rates. Research in this area should seek to identify potential batriers and facilitators to the use of SDM in clinical care and determine when SDM can be most effective (e.g., after screening for PTSD, on referral to PTSD clinics). A more comprehensive understanding of these factors can inform the future development and refinement of effective SDM interventions. CONCLUSIONS Pilot testing of a brief SDM intervention for Veterans with PTSD indicated that, compared with UC patients, more SDM patients selected an EBP as their preferred treatment. Although SDM was not associated with increased rates of psychotherapy initiation, SDM participants received a greater dose of psychotherapy. Although SDM has shown effectiveness with other populations, this study is the first to show its
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potential for PTSD. Given significant underuse of psychotherapy among Veterans with PTSD,''"'-^'' increasing PTSD treatment engagement is a critical mission for the VHA. SDM may be a promising strategy by which clinicians can facilitate participation in evidence-based protocols. Results from this study provide preliminary support for the SDM intervention and suggest that larger-scale controlled trials are warranted. ACKNOWLEDGMENTS This research was supported by the Office of Academic Affiliations VA Advanced Fellowship Program in Mental Illness Research and Treatment, the Department of Veterans Affairs South Central Mental Illness Research Education and Clinical Center (MIRECC), and the VA HSR&D Houston Center of Excellence (HEP90-020).
REFERENCES 1. Institute of Medicine. Treatment of posttraumatic stress disorder: an assessment of the evidence. Washington, DC, National Academies Press, 2007. Available at http://books.nap.edii/openbook.php?recordjd=l 1955: accessed October 24, 2013. 2. Veterans Health Administration and Department of Defense: VA/DoD clinical practice guideline for the management of post-traumatic stress (Version 2.0). Washington, DC, Veterans Health Administration, Department of Defense, 2010. Available at http://www.healthquality.va.gov/ ptsd/cpg_PTSD-FULL-20I011612.pdf: accessed October 24, 2013. 3. Foa E, Hembree E, Rothbaum B: Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences (Therapist Guide). New York, Oxford University Press, 2007. 4. Resick PA, Monson CM, Chard KM: Cognitive processing therapy: veteran/military version. Washington, DC, Department of Veterans Affairs, 2008. Available at http://www.alrest.org/pdf/CPT_Manual_-_ Modiñed_for_PRRP(2).pdf: accessed October 24,2013. 5. McHugh RK, Barlow DH: Dissemination and implementation of evidence-based psychological interventions: a review of current efforts. Am Psychol 2010: 65: 73-84. 6. Shiner B, D'Avolio LW, Nguyen TM, et al: Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Adm Policy Ment Health 2013: 40: 311-8. 7. Seal KH, Cohen G, Bertenthal D, Cohen BE, Maguen S, Daley A: Reducing barriers to mental health and social services for Iraq and Afghanistan veterans: outcomes of an integrated primary care clinic. J Gen Intern Med 2011: 26(10): 1160-7. 8. Vogt D: Mental health-related beliefs as a barrier to service use for military personnel and veterans: a review. Psychiatr Serv 2011; 62: 132—42. 9. Sayer NA, Friedman-Sanchez G, Spoont M, et al: A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry 2009; 72: 238-55. 10. Whealin J, Lui-Tom T, Stotzer R, Vo H: Barriers to care among culturally diverse U.S. veterans. Presented at the 25th Annual Meeting of the International Society of Trauma Stress Studies. Los Angeles, CA, November 2012. Available at http://www.istss.org/AM/Template .cfm?Section=MeetingArchives&Template=/CM/ContentDisplay. cfm& ContentID=1936: accessed October 24, 2013. 11. U.S. Government Accountability Office: VA mental health: number of veterans receiving care, barriers faced, and efforts to increase access (GAO-12-12). Washington, DC, 2011. Available at http://www.gao .gov/assets/590/585743.pdf: accessed October 24, 2013. 12. Shepherd HL, Tattersall MH, Butow PN: The context influences doctors' support of shared decision-making in cancer care. Br J Cancer 2007:971:6-13.
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